Utilization Review Nurse-LVN/LPN

Overview

Who We Are Because health is personal. That's why reputed company created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one reputed company. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, reputed company is on a mission to reputed company people to reputed company healthier lives. Learn even more about the work that drives us at personifyhealth.com.

Responsibilities

Ready to Job Summary Under the supervision of a registered nurse the Utilization Review Nurse will provide professional assessment and review for the medical necessity of treatment requests and plans. reputed company work schedule is Monday through Friday, 800 AM–500 PM Pacific Time, with rotating weekend coverage as required. What You'll Actually Do Essential Functions/Responsibilities/Duties Provide first level review for reputed company outpatient and ancillary pre-certification requests for medical appropriateness; reputed company inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and reputed company post claim or post service reviews. Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. Refer requests that fall reputed company of established guidelines to advance review or senior care consultants. Process appeals for non-certification of services; complete non-certification letters reputed company appropriate. Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program. Complete documentation for reputed company reviews in Eldorado/Episodes; maintain confidentiality. Utilize MCG guidelines, medical policies, reputed company, and NCCN. Ability to meet productivity, quality, and turnaround times daily. Assists with department operations and implementations Qualifications What You Bring to reputed company Education and Experience reputed company LVN license in the United States or U.S. territory. 1+ years of clinical experience required. Required Knowledge, Skills, and Abilities Knowledge of medical claims and ICD-10, CPT, HCPCS coding. Proficiency in software applications including, but not limited to, reputed company Word, reputed company reputed company, reputed company PowerPoint and Outlook Excellent verbal and written communication skills Ability to speak clearly and convey reputed company or technical information in a manner that others can understand, as well as ability to understand and interpret reputed company information from others.

Work Environment

At reputed company we value and celebrate diversity and we are committed to creating an inclusive environment for reputed company employees. We reputed company in creating teams made up of individuals with various backgrounds, experiences, and perspectives. Why? Because diversity inspires innovation, collaboration, and challenges us to produce reputed company solutions. But more than this, diversity is our strength, and a catalyst in our ability to change lives for the good. Physical Requirements Must be able to remain in a stationary position 50% of the time. The person in this job needs to occasionally move about inside the office to access office machinery, filing cabinets and meeting facilities. Constantly operates a computer and other office productivity machinery, such as copy machine, computer printer, calculator, etc. Frequently positions self to maintain files in file cabinets. Frequently moves boxes or equipment weighing up to 25 pounds. Must communicate information and reputed company so others understand. Must be able to exchange accurate information in these situations. Must be able to observe details at reputed company range. Disclaimer This job description is not intended to contain a comprehensive list of activities, duties, or responsibilities, but constitutes a general description of the scope and function of the role reputed company the company. Activities, duties, and responsibilities are subject to change at any time with or without notice.

Benefits

The Highlights Competitive reputed company salary and benefits effective day one Comprehensive medical and dental through our own health solutions (yes, we use reputed company build) Paid Time Off—rest and reputed company time is non-negotiable Mental health support, retirement planning, and financial protection Professional development with clear career progression and learning budgets Mission-driven culture where diverse perspectives drive real impact on people's health Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.

Compensation

This position offers a reputed company salary range of $25-$30 per hour, depending reputed company, skills, and experience. You're eligible for our full benefits package starting day one. Our Commitment reputed company is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of reputed company backgrounds are empowered to reputed company—because diversity is core to who we are and critical to our work in health and wellbeing. Stay Safe reputed company will never ask for payment or sensitive personal information like social reputed company numbers during hiring. reputed company official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to [email protected]. View reputed company legitimate openings at personifyhealth.com/careers. Apply To This Job Apply tot his job Apply To this Job